303
(0 4-6 8 x 109/1), a property much exploited in experimental immunology, but without any apparent consequence in chylothorax. In view of the metabolic complications, many now favour early intervention. It is perhaps worth waiting a week for spontaneous resolution, but then surgical ligation of the thoracic duct should be undertaken. During the initial period of conservative treatment, the amount of chyle passing through the duct from the intestine can be reduced by feeding the patient intravenously. Only when the general condition precludes thoracotomy may longer periods of conservative treatment be necessary. Before operation, lymphangiography by the bipedal route will often show the site of leakage,5 and four hours before operation the patient should be given double cream: the consequent issue of milk-white chyle will usually make identification and ligation of the thoracic duct a simple matter
for the surgeon.
PERITONEAL DIALYSIS IN CHRONIC RENAL FAILURE
PERITONEAL dialysis has a well established place in the management of acute renal failure. In the long-term management of chronic renal failure it is more controversial, largely because of peritonitis. A previous editorial6 commented on the encouraging results of Tenckhoff and his colleagues7 in 69 patients treated for 3-68 months: only 0.6% of all dialyses were complicated by which was never fatal. The key to this suchave been a modification of the indwelling silicone/rubber catheter devised by Palmer et awl. 89 Tenckhoff employs a ’Dacron’ felt cuff which acts as an anchor and infection barrier.1O His group also use a closed automated peritoneal dialysis fluid supply system, and sterile pyrogen-free fluid is prepared at the bedside by reverse osmosis. Most of Tenckhoff’s patients were treated at home for 12 hours overnight, three times a week. Biochemical control of the renal failure was acceptable and the patients’ wellbeing and rehabilitation were rated as good as those of patients on maintenance hxmodialysis. But the results of Lankisch and others,11 also using Tenckhoff catheters, were not good. The incidence of peritonitis was high, and these workers thought peritoneal dialysis of value only as a short-term measure. However, they do not make clear whether they used a closed automated fluid-delivering system. A high incidence of peritonitis has also been encountered with the repeated-puncture technique, in which a fresh polyethylene peritoneal catheter is inserted at each dialysis and removed at the end of dialysis.12 In many
peritonitis,
cess seems to
5.
Schulman, A., Fataar, S., Dalrymple, R., Tidbury, I. Br. J. Radiol. 1978, 51,420. 6.Lancet, 1974, i, 18. 7. Tenckhoff, H., Blagg, C. R., Curtis, K. F., Hickman, R. O. Proc. Eur. Dial. Transplant. Ass. 1973, 10, 363. 8. Palmer, R. A., Quinton, W. E., Gray, J. E. Lancet, 1964, i, 700. 9. Palmer, R. A., Newell, J. E., Gray, J. E., Quinton, W. E. New Eng J. Med. 1966, 274, 248. 10. Tenckhoff, H., Schechter, H. Trans. Am. Soc. artif. intern. Org. 1968, 14, 181. 11. Lankisch, P. G., Tönnis, H. J., Fernandez-Redo, E., Girndt, Quellhorst, E., Scheler, F. Br. med. J. 1973, iv, 712. 12. Mion, C. Proc. Eur. Dial. Transplant. Ass. 1975, 12, 140.
J., Kramer, P.,
series, however, the multiple puncture technique has been used without a closed automated-delivery system, thereby increasing the risks of peritoneal infection. Not all episodes of peritonitis during long-term peritoneal dialysis are due to infection, 15-30% being aseptic. Karanicolas et al. 13 have reported an epidemic of aseptic peritonitis caused by endotoxin in dialysis fluid. Popovich and his co-workers 14 devised a regimen for chronic renal failure which they call continuous ambulatory peritioneal dialysis (C.A.P.D.). They have just reported their experience with this technique in 9 patients treated for between 5 and 26 weeks. 15 All patients had indwelling Tenckhoff peritoneal catheters, the exterior end of the catheter being capped and held in place by a gauze belt. In this technique dialysis fluid is present in the peritoneal cavity 24 hours a day, 7 days a’week, apart from brief intervals five times a day when old fluid is drained and 2 litres of fresh solution instilled (from commercial bags). Thus instead of 3 x 12 h overnight dialysis per week, these patients have five interruptions of 30-45 minutes each day for drainage of peritoneal dialysis fluid by gravity (15-20 min) and infusion of 2 litres of fresh dialysis fluid (10 min). Most of the patients carry out the fluid drainage/instillation cycles at about 0700, 1100, 1500, 1900, and 2200 h. After each fresh infusion of dialysis fluid the delivery tubing is disconnected and the catheter is recapped. Biochemical control of renal failure was regarded as acceptable, with a steady-state mean serum-urea-nitrogen of 59 mg/dl at 6 weeks and mean serum-creatinine of 10-12 mg/dl. The patients had a high protein intake of 1 g/kg bodyweight or more, and hypoproteinæmia did not develop. 50 mg potassium was also given each day. There were no particular problems with the control of hyperkalæmia, hypertension, or cedema. The major trouble was again peritonitis-not surprisingly in view of the number of drainage/inflow procedures. The average was one episode of infection every 10 weeks or one episode every 350 drainage/inflow procedures (0.29%). Popovich et al. conclude that until the incidence of peritonitis can be reduced, perhaps by better peritoneal-fluid delivery systems and coupling devices, then C.A.P.D. cannot be recommended for general use. Most people would agree with this. Is there a need for long-term peritoneal dialysis in chronic renal failure? In certain circumstances, yes. Thus in the small child in whom blood access is difficult, or in the adult who has lost all shunt or fistula access sites for haemodialysis, then long-term peritoneal dialysis may be the only hope apart from renal transplantation. It may also have a place for those patients unable to master home haemodialysis. Of course peritoneal dialysis is also a very valuable holding manoevre in those patients awaiting places on hxmodialysis or transplantation programmes. Other possible indications include the elderly patient with chronic renal failure and the diabetic with terminal diabetic nephropathy. 16
13. Karanicolas, S., Oreopoulos, D. G., Izatt, S., Shimizu, A., Manning, R. F., Sepp, H., de Veber, G. A., Darby, T. New Engl J. Med. 1977, 296, 1336. 14. Popovich, R. P., Moncrief, J. W., Decherd, J. B., Bomar, J. B., Pyle, W. K. Abstr. Am. Soc. artif.Intern. Org. 1976, 5, 64. 15. Popovich, R. P., Moncrief, J. W., Nolph, K. D., Ghods, A. J., Twardowski, Z. J., Pyle, W. K. Ann. intern. Med. 1978, 88, 449. 16. Kolff, W. J. Proc. Eur. Dial. Transplant Ass. 1975, 12, 153.
(0 4-6 8 x 109/1), a property much exploited in experimental immunology, but without any apparent consequence in chylothorax. In view of the metabolic complications, many now favour early intervention. It is perhaps worth waiting a week for spontaneous resolution, but then surgical ligation of the thoracic duct should be undertaken. During the initial period of conservative treatment, the amount of chyle passing through the duct from the intestine can be reduced by feeding the patient intravenously. Only when the general condition precludes thoracotomy may longer periods of conservative treatment be necessary. Before operation, lymphangiography by the bipedal route will often show the site of leakage,5 and four hours before operation the patient should be given double cream: the consequent issue of milk-white chyle will usually make identification and ligation of the thoracic duct a simple matter
for the surgeon.
PERITONEAL DIALYSIS IN CHRONIC RENAL FAILURE
PERITONEAL dialysis has a well established place in the management of acute renal failure. In the long-term management of chronic renal failure it is more controversial, largely because of peritonitis. A previous editorial6 commented on the encouraging results of Tenckhoff and his colleagues7 in 69 patients treated for 3-68 months: only 0.6% of all dialyses were complicated by which was never fatal. The key to this suchave been a modification of the indwelling silicone/rubber catheter devised by Palmer et awl. 89 Tenckhoff employs a ’Dacron’ felt cuff which acts as an anchor and infection barrier.1O His group also use a closed automated peritoneal dialysis fluid supply system, and sterile pyrogen-free fluid is prepared at the bedside by reverse osmosis. Most of Tenckhoff’s patients were treated at home for 12 hours overnight, three times a week. Biochemical control of the renal failure was acceptable and the patients’ wellbeing and rehabilitation were rated as good as those of patients on maintenance hxmodialysis. But the results of Lankisch and others,11 also using Tenckhoff catheters, were not good. The incidence of peritonitis was high, and these workers thought peritoneal dialysis of value only as a short-term measure. However, they do not make clear whether they used a closed automated fluid-delivering system. A high incidence of peritonitis has also been encountered with the repeated-puncture technique, in which a fresh polyethylene peritoneal catheter is inserted at each dialysis and removed at the end of dialysis.12 In many
peritonitis,
cess seems to
5.
Schulman, A., Fataar, S., Dalrymple, R., Tidbury, I. Br. J. Radiol. 1978, 51,420. 6.Lancet, 1974, i, 18. 7. Tenckhoff, H., Blagg, C. R., Curtis, K. F., Hickman, R. O. Proc. Eur. Dial. Transplant. Ass. 1973, 10, 363. 8. Palmer, R. A., Quinton, W. E., Gray, J. E. Lancet, 1964, i, 700. 9. Palmer, R. A., Newell, J. E., Gray, J. E., Quinton, W. E. New Eng J. Med. 1966, 274, 248. 10. Tenckhoff, H., Schechter, H. Trans. Am. Soc. artif. intern. Org. 1968, 14, 181. 11. Lankisch, P. G., Tönnis, H. J., Fernandez-Redo, E., Girndt, Quellhorst, E., Scheler, F. Br. med. J. 1973, iv, 712. 12. Mion, C. Proc. Eur. Dial. Transplant. Ass. 1975, 12, 140.
J., Kramer, P.,
series, however, the multiple puncture technique has been used without a closed automated-delivery system, thereby increasing the risks of peritoneal infection. Not all episodes of peritonitis during long-term peritoneal dialysis are due to infection, 15-30% being aseptic. Karanicolas et al. 13 have reported an epidemic of aseptic peritonitis caused by endotoxin in dialysis fluid. Popovich and his co-workers 14 devised a regimen for chronic renal failure which they call continuous ambulatory peritioneal dialysis (C.A.P.D.). They have just reported their experience with this technique in 9 patients treated for between 5 and 26 weeks. 15 All patients had indwelling Tenckhoff peritoneal catheters, the exterior end of the catheter being capped and held in place by a gauze belt. In this technique dialysis fluid is present in the peritoneal cavity 24 hours a day, 7 days a’week, apart from brief intervals five times a day when old fluid is drained and 2 litres of fresh solution instilled (from commercial bags). Thus instead of 3 x 12 h overnight dialysis per week, these patients have five interruptions of 30-45 minutes each day for drainage of peritoneal dialysis fluid by gravity (15-20 min) and infusion of 2 litres of fresh dialysis fluid (10 min). Most of the patients carry out the fluid drainage/instillation cycles at about 0700, 1100, 1500, 1900, and 2200 h. After each fresh infusion of dialysis fluid the delivery tubing is disconnected and the catheter is recapped. Biochemical control of renal failure was regarded as acceptable, with a steady-state mean serum-urea-nitrogen of 59 mg/dl at 6 weeks and mean serum-creatinine of 10-12 mg/dl. The patients had a high protein intake of 1 g/kg bodyweight or more, and hypoproteinæmia did not develop. 50 mg potassium was also given each day. There were no particular problems with the control of hyperkalæmia, hypertension, or cedema. The major trouble was again peritonitis-not surprisingly in view of the number of drainage/inflow procedures. The average was one episode of infection every 10 weeks or one episode every 350 drainage/inflow procedures (0.29%). Popovich et al. conclude that until the incidence of peritonitis can be reduced, perhaps by better peritoneal-fluid delivery systems and coupling devices, then C.A.P.D. cannot be recommended for general use. Most people would agree with this. Is there a need for long-term peritoneal dialysis in chronic renal failure? In certain circumstances, yes. Thus in the small child in whom blood access is difficult, or in the adult who has lost all shunt or fistula access sites for haemodialysis, then long-term peritoneal dialysis may be the only hope apart from renal transplantation. It may also have a place for those patients unable to master home haemodialysis. Of course peritoneal dialysis is also a very valuable holding manoevre in those patients awaiting places on hxmodialysis or transplantation programmes. Other possible indications include the elderly patient with chronic renal failure and the diabetic with terminal diabetic nephropathy. 16
13. Karanicolas, S., Oreopoulos, D. G., Izatt, S., Shimizu, A., Manning, R. F., Sepp, H., de Veber, G. A., Darby, T. New Engl J. Med. 1977, 296, 1336. 14. Popovich, R. P., Moncrief, J. W., Decherd, J. B., Bomar, J. B., Pyle, W. K. Abstr. Am. Soc. artif.Intern. Org. 1976, 5, 64. 15. Popovich, R. P., Moncrief, J. W., Nolph, K. D., Ghods, A. J., Twardowski, Z. J., Pyle, W. K. Ann. intern. Med. 1978, 88, 449. 16. Kolff, W. J. Proc. Eur. Dial. Transplant Ass. 1975, 12, 153.
